Idacio — Medica
any FDA-approved indication for adalimumab products
Preferred products
- Cyltezo
- adalimumab-adbm
- adalimumab-adaz
- Simlandi
- adalimumab-ryvk
Initial criteria
- Patient meets the standard Inflammatory Conditions – Adalimumab Products Prior Authorization Policy criteria; AND
- Patient has tried ALL of Cyltezo/adalimumab-adbm, adalimumab-adaz, and Simlandi/adalimumab-ryvk [documentation required]; AND
- Patient cannot continue to use ALL Preferred medications (Cyltezo/adalimumab-adbm, adalimumab-adaz, Simlandi/adalimumab-ryvk) due to formulation differences in inactive ingredient(s) (e.g., stabilizing agent, buffering agent, surfactant) which, according to the prescriber, would result in a significant allergy or serious adverse reaction [documentation required]
Reauthorization criteria
- Same criteria as initial per standard Inflammatory Conditions – Adalimumab Products Prior Authorization Policy
Approval duration
as noted in the standard Inflammatory Conditions – Adalimumab Products Prior Authorization Policy